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COCHRANE BVS
BIREME OPAS
OMS
Imprimir | Cerrar
Copyri ght: The Cochrane Li brary
CORTICOSTEROIDS FOR HELLP SYNDROME IN PREGNANCY
Matchaba Patrice T, Moodley Jagidesa
Matchaba Patrice T, Moodley Jagidesa
Cochrane Database of Systematic Reviews, Issue 7, 2013 (Status in this issue: WITHDRAWN FROM PUBLICATION FOR
REASONS STATED IN THE REVIEW)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DOI: 10.1002/14651858.CD002076.pub1
This review should be cited as: Matchaba Patrice T, Moodley Jagidesa. Corticosteroids for HELLP syndrome in
pregnancy. Cochrane Database of Systematic Reviews. In: The Cochrane Library, Issue 7, Art. No. CD002076. DOI:
10.1002/14651858.CD002076.pub1
A B S T R A C T
Background
Hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome is a severe form of pre-eclampsia. Pre-
eclampsia is a multi-system disease of pregnancy associated with an increase in blood pressure and increased
perinatal and maternal morbidity and mortality. Eighty per cent of women with HELLP syndrome present before term.
There are suggestions from observational studies that steroid treatment in HELLP syndrome may improve disordered
maternal hematological and biochemical features and perhaps perinatal mortality and morbidity.
Objective
To summarise the evidence on the effects of corticosteroids on maternal and neonatal mortality and morbidity in
women with HELLP syndrome.
Criteria for considering studies for this review
We searched the Cochrane Pregnancy and Childbirth Group trials register (October 2003). We scanned lists of
references from review articles and primary studies.
Selection criteria
Randomised and quasi-randomised trials evaluating the effects of adjunctive corticosteroids in patients diagnosed with
HELLP syndrome were sought.
Data collection and analysis
The two authors independently applied inclusion criteria, assessed trial quality and extracted relevant data.
Main results
Of the five studies reviewed (n = 170), three were conducted antepartum and two postpartum. Four of the studies
randomised participants to standard therapy or dexamethasone. One study compared dexamethasone with
betamethasone.
Dexamethasone versus control
There were no significant differences in the primary outcomes of maternal mortality and morbidity due to placental
abruption, pulmonary oedema and liver hematoma or rupture. Of the secondary maternal outcomes, there was a
tendency to a greater platelet count increase over 48 hours, statistically significantly less mean number of hospital
stay days (weighted mean difference (WMD) -4.50, 95% confidence interval (CI) -7.13 to -1.87), mean interval
(hours) to delivery (41 15) versus (15 4.5) (p = 0.0068) in favour of women allocated to dexamethasone.
Authors' conclusions
There is insufficient evidence to determine whether adjunctive steroid use in HELLP syndrome decreases maternal and
perinatal mortality, major maternal and perinatal morbidity.
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P L A I N L A N G U A G E S U M M A R Y
More research is needed to determine if corticosteroids can improve outcomes for women and babies affected by
HELLP syndrome in pregnancy.
Pre-eclampsia, also known as toxaemia, is a potentially life-threatening condition of pregnancy. It involves high blood
pressure (hypertension) and protein in the urine. HELLP syndrome (hemolysis, elevated liver enzymes and low
platelets) is a severe form of pre-eclampsia, which can cause a tendency to bleed and other complications.
Corticosteroids may be able to normalise some of the abnormal biochemical changes caused by HELLP, as well as
reduce hypertension. The review of trials of corticosteroids for women with HELLP (both during pregnancy and after
the birth) found too little evidence to be sure of the effects, but more research is worthwhile.
W H A T ' S N E W
What's new
Last assessed as up-to-date: 30 October 2003.
Date Event Description
11 May 2009 Amended Review withdrawn from publication.
B A C K G R O U N D
Hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome is a severe form of pre-eclampsia ( Pritchard
1954 ). Pre-eclampsia is a condition associated with an increase in blood pressure, protein loss via the urine, and
oedema in pregnancy and occurs in 5% to 8% of all pregnancies. Its cause is not known, but it remains a major cause
of perinatal and maternal morbidity and mortality ( Duley 1992 ). HELLP syndrome occurs in about 20% of severely
pre-eclamptic women and does so before term in 80% of cases; 10% of these occur before 27 weeks' gestation (
Sibai 1993 ). Premature delivery contributes to the very high rate of perinatal morbidity and mortality. About a third
of the cases are diagnosed for the first time postpartum ( Sibai 1993 ).
Although it is agreed that hemolysis, liver dysfunction and thrombocytopenia must be present to make a diagnosis of
HELLP syndrome, there is disagreement over the specific biochemical and hematological criteria to be used. For the
purposes of this review, the criteria specified by Sibai ( Sibai 1986 ) and Martin ( Martin 1991 ) will be used. Sibai's
criteria include hemolysis as evidenced by an abnormal peripheral smear, lactate dehydrogenase (LDH) greater than
600 IU/L or Total Bilirubin (TB) greater than 1.2 ULN; elevated liver enzymes as evidenced by an aspartate
transaminase (AST) greater than 70 IU/L and platelets less than 100 000/mm. Martin's criteria include hemolysis as
evidenced by a falling hematocrit, LDH greater than 164 IU/L or a bleeding diathesis; elevated liver enzymes as
evidenced an AST greater than 48 IU/L and alanine transaminase (ALT) greater than 24 IU/L and platelets less than
100 000 mm.
Maternal mortality (1% to 3.5%) and morbidity are increased by the hypertensive complications of pre-eclampsia, the
bleeding tendency that results from the low platelets and liver dysfunction ( Sibai 1993 ; Weinstein 1985 ; Martin 1991
).
Since HELLP syndrome is common before term, any intervention that prolongs the time from diagnosis to delivery by
stabilising the clinical condition, may decrease perinatal morbidity and mortality. Steroids have been shown in
observational studies ( Magann 1993 ; Clark 1986 ; Yeast 1987 ) to improve the deranged maternal biochemical and
haematological indices associated with the syndrome. This benefit has also been shown in HELLP syndrome diagnosed
postpartum ( Martin 1997 ; Yalcin 1998 ). However, it may be argued that delaying delivery may worsen the maternal
morbidity and increase both maternal and fetal mortality.
Glucocorticoids have been shown to improve fetal lung maturation, decreasing the occurrence and severity of
respiratory distress syndrome and the overall fetal morbidity and mortality after preterm birth ( Crowley 1999 ).
Dexamethasone at doses up to a total of 48 mg over a 48 hour period may be given intramuscularly in order to
improve fetal lung function. However, the steroid dosing regimens that have been suggested for HELLP syndrome are
different from the one used for fetal lung maturation. The maternal and fetal effects of such a regimen have not been
quantified. Also, the number of women with HELLP syndrome who have been treated with steroids is probably small.
This review therefore aims to summarise existing evidence of the effects of steroids in HELLP syndrome. Any effects
may be different according to the gestational age, severity of disease, parity and whether the mother is antepartum
or postpartum. The effect estimates will be explored for these factors.
O B J E C T I V E S
(1) To evaluate the effects of corticosteroids in women with HELLP syndrome during pregnancy or shortly after
delivery.
The following primary hypothesis will be tested:
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In comparing women given steroids with control/placebo groups, there will be no difference in:
(a) maternal morbidity and mortality;
(b) perinatal morbidity and mortality.
(2) In addition, we will explore whether the possible effects of steroids on the mother differ according to:
(a) gestational age at treatment; and
(b) whether the mother is antepartum or postpartum.
M E T H O D S O F T H E R E V I E W
C R I T E R I A F O R C O N S I D E R I N G S T U D I E S F O R T H I S R E V I E W
Types of studies
All randomised controlled trials and trials which used pseudo-randomised methods, such as alternate allocation.
Types of participants
All antepartum and postpartum women diagnosed clinically and by biochemical parameters as having the HELLP
syndrome.
Types of intervention
Any corticosteroid versus placebo or no treatment.
Types of outcome measures
Primary outcomes
(1) maternal mortality;
(2) perinatal mortality;
(3) maternal morbidity, namely:
presence of liver hematoma and rupture;
pulmonary oedema;
renal failure;
abruptio placentae;
(4) perinatal morbidity, namely:
respiratory distress syndrome and ventilatory support required;
intracerebral haemorrhage;
necrotizing enterocolitis.
Secondary outcomes
(1) Maternal
After randomisation, the
average time taken to return to normal biochemical and haematological parameters;
average time taken to return to a normal urine output;
average time taken to return to a normal blood pressure;
average time to delivery;
mode of delivery.
(2) Neonatal
the mean gestational age and weight at birth;
the mean Apgar scores at birth.
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S E A R C H M E T H O D S F O R I D E N T I F I C A T I O N O F S T U D I E S
Search methods for identification of studies
Electronic searches
We searched the Cochrane Pregnancy and Childbirth Group trials register (October 2003).
The Cochrane Pregnancy and Childbirth Group's trials register is maintained by the Trials Search Co-ordinator and
contains trials identified from:
quarterly searches of the Cochrane Central Register of Controlled Trials (CENTRAL);
monthly searches of MEDLINE;
handsearches of 30 journals and the proceedings of major conferences;
weekly current awareness search of a further 37 journals.
Details of the search strategies for CENTRAL and MEDLINE, the list of handsearched journals and conference
proceedings, and the list of journals reviewed via the current awareness service can be found in the 'Search
strategies for identification of studies' section within the editorial information about the Cochrane Pregnancy and
Childbirth Group.
Trials identified through the searching activities described above are given a code (or codes) depending on the topic.
The codes are linked to review topics. The Trials Search Co-ordinator searches the register for each review using
these codes rather than keywords.
D A T A C O L L E C T I O N A N D A N A L Y S I S
Data collection and analysis
The inclusion criteria were applied to all identified trials by the two authors independently. Each included trial was
assessed in terms of adequacy of concealment of allocation, generation of allocation sequence, blinding and follow up
of subjects ( Clarke 2000 ).
Data extraction was undertaken by the two reviewers independently, who collected the following information for each
trial:
number of women;
women's characteristics including ethnic origin, parity, whether the women were antepartum or postpartum,
gestational age at diagnosis, number of babies in current pregnancy, the mode of delivery and time from diagnosis to
delivery;
the haematological and biochemical results;
morbidity and mortality outcomes;
the type, dose and duration of steroid used;
other medication used.
Babies' characteristics including ethnic origin, gestational age at birth, weight, Apgar scores and morbidity and
mortality outcomes.
It was intended to explore whether any heterogeneity of effect was explained by whether the woman was antepartum
or postpartum, the gestational age, severity of disease and parity.
M E T H O D O L O G I C A L Q U A L I T Y
R E S U L T S
Results
Description of studies
See: Characteristics of included studies .
Seven published studies were identified that met the inclusion criteria. One of the studies ( Kadanali 1997 ) has not
been included in the data analysis because it is being translated into English and another ( Isler 2003 ) has not been
included because we have asked for the original data. Of the five studies that have been analysed, four have
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compared steroid use (dexamethasone) with placebo ( Isler 2001 ; Magann 1994a ; Magann 1994b ; Yalcin 1998 :
Vigil-De Gracia 1997 ). One study compared two different steroid regimens ( Isler 2001 ). The total number of trial
participants in the five studies is 170.
Three of the reviewed studies were conducted antepartum ( Isler 2001 ; Magann 1994b ; Vigil-De Gracia 1997 ). The
other two were conducted postpartum ( Magann 1994a ; Yalcin 1998 ).
Risk of bias in included studies
Three studies employed adequate randomisation and allocation concealment methods ( Isler 2001 ; Magann 1994a ;
Magann 1994b ). However, in Magann 1994b , women allocated to standard treatment (control) had higher mean
platelet counts than those allocated to steroid treatment.
In the two other studies ( Yalcin 1998 ; Vigil-De Gracia 1997 ), there was no mention of the randomisation method
used, nor whether allocation concealment was implemented. Furthermore in Vigil-De Gracia 1997 , the groups
randomly allocated to standard therapy differed in the maternal platelet count when compared with the group
allocated to steroid therapy, the platelet count being lower in the group randomly allocated to receive steroids. None
of the trials were placebo-controlled.
In none of the five included studies was blinding described in the methods section.
There was significant loss to follow up in one study ( Magann 1994a ). Only 25 of the original 40 participants
randomised were accounted for in the results section. Intention to treat analysis was not performed in this study. The
other studies had no loss to follow up.
Effects of interventions
Five studies involving 170 women are included.
1. Primary outcomes
Trials that compared dexamethasone plus standard therapy versus standard therapy alone
There were four trials that used this study design ( Magann 1994a ; Magann 1994b ; Yalcin 1998 ; Vigil-De Gracia
1997 ).
Maternal mortality
There was one maternal death in the group randomised to standard therapy ( Vigil-De Gracia 1997 , n = 34) and this
was not statistically significant (relative risk (RR) 0.33, 95% confidence interval (CI) 0.01 to 7.65).
Perinatal mortality
There was no statistically significant difference in neonatal deaths (RR 0.36, 95% CI 0.04 to 3.02) in the one study (n
= 25).
Maternal morbidity
There were no cases of liver hematoma or rupture, pulmonary oedema, renal failure or placental abruption in either
group.
Perinatal morbidity
i) Intraventricular hemorrhage events occurred in one study ( Magann 1994b , n = 25) and the difference was not
statistically significant (RR 7.54, 95% CI 0.43 to 132.35).
ii) Respiratory distress syndrome events occurred in one study ( Magann 1994b ) and there was no statistically
significant difference (RR 1.00, 95% CI 0.25 to 4.00).
iii) Retrolental fibroplasia occurred in one neonate allocated to placebo ( Magann 1994b ) but the difference was not
statistically significant (RR 0.36, 95% CI 0.02 to 8.05).
No intracerebral hemorrhagic events nor necrotizing enterocolitis were recorded.
Trial that compared dexamethasone and betamethasone
There was only one study with this design ( Isler 2001 , n = 40).
Maternal mortality
There were no maternal deaths.
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Perinatal mortality
There was no significant difference in neonatal deaths when dexamethasone was compared with betamethasone (RR
0.95, 95% CI 0.15 to 6.08).
Maternal morbidity
There were no cases of liver hematoma or rupture, pulmonary oedema, or abruptio placentae in either group. There
was a statistically significant difference in maternal oliguria (RR 0.06, 95% CI 0.00 to 0.93) in favour of participants
randomised to dexamethasone.
Perinatal morbidity
There was a tendency for fewer neonates allocated to dexamethasone to have ventilatory support or respiratory
distress syndrome when compared with those allocated to betamethasone. However, this was not statistically
significant (RR 0.54, 95% CI 0.19 to 1.56). In this study, no cases of intracerebral hemorrhage and necrotizing
enterocolitis were recorded.
2. Secondary outcomes
Trials that compared dexamethasone plus standard therapy versus standard therapy alone
Maternal morbidity
i) There was no statistically significant difference in postpartum sepsis (RR 2.00, 95% CI 0.20 to 19.78) in one study
(n = 30) and cesarean sections (RR 0.93, 95% CI 0.66 to 1.31) between the two groups (one study, n = 34).
ii) There was a tendency to a greater platelet count increase over 48 hours in participants allocated to dexamethasone
(weighted mean difference (WMD) 40.60, 95% CI -26.12 to 107.32) but this result must be interpreted with caution
because the data are skewed and are derived from only one small study ( Vigil-De Gracia 1997 , n=34).
iii) There was a statistically significant difference in the mean number of hospital stay days postrandomisation (WMD
-4.50, 95% CI -7.13 to -1.87) in favour of participants allocated to dexamethasone.
iv) There was a significant difference in the mean interval (hours) from randomisation to delivery (41 15) versus
(15 4.5) (p = 0.0068) in favour of women allocated to dexamethasone in the single study that looked at this
outcome ( Magann 1994b , n = 25).
Neonatal morbidity
The number of neonates with a five minute Apgar less than seven did not differ significantly (RR 1.00 95% CI 0.25 to
4.00): one study, n = 24. The mean weight at birth was significantly greater in the group allocated to steroids (WMD
247.00, 95% CI 65.41 to 428.59).
Trial that compared dexamethasone and betamethasone
Maternal morbidity
There was a statistically significant difference in favour of participants allocated to dexamethasone in the adjusted
time-average change from baseline in the following secondary outcomes:
i) The mean arterial pressure decrease (WMD -7.50, 95% CI -8.37 to -6.63).
ii) The mean increase in urinary output (WMD 24.80, 95% CI 19.58 to 30.02).
iii) The mean increase in platelet count (WMD 8.10, 95% CI 6.23 to 9.97).
iv) The mean decrease in lactate dehydrogenase activity (U/L) (WMD -54.20, 95% CI -88.22 to -20.18).
v) The mean decrease in aspartate transaminase activity (U/L) (WMD -30.30, 95% CI -36.06 to -24.54).
The number of participants needing acute antihypertensive therapy in the dexamethasone group differed significantly
statistically compared with those allocated to betamethasone (RR 0.29, 95% CI 0.12 to 0.73).
Neonatal morbidity
There were no statistically significant differences between the two groups with regards to the number of neonates with
a five minute Apgar less than seven (RR 0.95, 95% CI 0.22 to 4.14), neonatal sepsis (RR 4.76, 95% CI 0.24 to
93.19), neonatal hyperbilirubinemia (RR 2.85, 95% CI 0.32 to 25.07) and mean time to discharge in days (WMD
-5.40, 95% CI -19.53 to 8.73).
There was no trial that compared betamethasone plus standard therapy versus standard therapy alone.
D I S C U S S I O N
Discussion
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Trials that compared participants randomised with steroid (dexamethasone) use and placebo (Magann
1994a; Magann 1994b; Vigil-De Gracia 1997; Yalcin 1998).
HELLP syndrome is a severe form of pre-eclampsia ( Pritchard 1954 ), whose cause is unknown and remains a major
cause of perinatal morbidity and mortality ( Duley 1992 ). In this review there was no statistically significant
difference in the primary outcome of maternal mortality (relative risk (RR) 0.33, 95% confidence interval (CI) 0.01 to
7.65). There was one maternal death in the group allocated to placebo in a trial with a total of 34 participants ( Vigil-
De Gracia 1997 ). Besides the small sample size of this trial, the randomisation method used was not mentioned and
the methodology used for allocation concealment is unclear. Furthermore the postrandomisation patient characteristics
differed significantly with regards to platelet count, before treatment was instituted.
There were four neonatal deaths in one small trial ( Magann 1994b , n = 25), which were not statistically significant
(RR 0.36, 95% CI 0.04 to 3.02). Although allocation concealment and randomisation were adequate in this trial,
maternal platelet levels differed significantly postrandomisation before treatment commenced (p = 0.034) and the
ratio of black to female participants was 2:1.
Maternal morbidity primary outcomes of pulmonary oedema, presence of a liver hematoma or rupture, renal and
abruptio placentae did not differ significantly between the two groups of participants.
None of the primary perinatal morbidity outcomes, respiratory distress syndrome, need for ventilatory support,
intracerebral hemorrhage and necrotizing enterocolitis, differed significantly.
The only secondary maternal morbidity outcome that was statistically significant in favour of steroid use was the mean
number of days of hospital stay (weighted mean difference (WMD) -4.50, 95% CI -7.13 to -1.87). The number of
neonates with Apgar scores less than seven after five minutes were not significantly different. The mean weight at
birth differed significantly (WMD 247.00, 95% CI 65.41 to 428.59) in one study ( Magann 1994b ).
In summary, because of the small sample sizes in the trials reviewed, there is no evidence that either supports or
refutes the use of steroids in HELLP syndrome antenatally and in the postpartum period in order to decrease or
increase maternal and perinatal mortality and the primary morbidity outcomes of interest in this review.
One trial compared dexamethasone use with betamethasone (Isler 2001):
There were no maternal or neonatal primary outcome differences with regards to death and maternal morbidity, with
the exception of oliguria (less than 30 ml urine/hour for two hours) (RR 0.06, 95% CI 0.00 to 0.93), in favour of
dexamethasone.
The main findings were in the maternal hematological and biochemical parameters. In all instances of adjusted time-
average change from baseline for mean arterial pressure decrease, mean increase in the platelet count, mean
decrease in lactate dehydrogenase and aspartate transaminase activity and the need for acute antihypertensive
therapy, women allocated to dexamethasone fared better significantly than those allocated to betamethasone. This is
supportive of the observational data referenced above that had similar findings.
There were no significant differences in the secondary neonatal outcomes of Apgar score of less than seven after five
minutes, neonatal sepsis, hyperbilirubinaemia and time to discharge from hospital.
In summary, because of the small sample size there is no evidence from this trial that indicates that when
dexamethasone is given intravenously (10 mg 12 hourly before delivery), that there is a statistically significant
difference in the maternal biochemical and hematological parameters when compared with betamethasone (12 mg
intramuscularly every 24 hours).
A U T H O R S ' C O N C L U S I O N S
Implications for practice
Until a large enough study that is adequately designed with sufficient power to detect a significant difference in the
primary maternal and neonatal outcomes of death and severe morbidity, there is no evidence to support the addition
of dexamethasone or betamethasone to standard therapy in HELLP syndrome. However, it is important to note that
glucocorticoids have been shown to improve fetal lung maturity and overall fetal mortality and morbidity when the
appropriate dosing regimens are used ( Crowley 1999 ).
Implications for research
The high maternal and perinatal mortality and morbidity associated with HELLP syndrome makes it imperative that a
large study with the appropriate design be done to determine the effect of antenatal and postpartum steroids on the
primary and secondary outcomes chosen in this review. Steroids are relatively cheap and if found efficacious in
decreasing the primary outcomes sought in the review, they would provide a cost-effective intervention for HELLP
syndrome. Because HELLP syndrome is not very common ( Sibai 1993 ), a global multi-centre study design may be
the most efficient study design to use in order to recruit sufficient patients to adequately answer the review question.
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A C K N O W L E D G E M E N T S
Acknowledgements
Contributions: Jim Neilson, Michel Boulvain, the Cochrane Pregnancy and Childbirth Group's panel of consumers.
N O T E S
R E F E R E N C E S
References to studies included in this review
Isler 2001 {published data only}
Isler C, Barrilleaux P, Magann E, Bass J, Martin J. A prospective, randomized trial comparing the
efficacy of dexamethasone and betamethasone for the treatment of antepartum HELLP (hemolysis,
elevated liver enzymes, and low platelet count) syndrome. Revista Chilena de Obstetricia y Ginecologia
2001;66(3):248-50.
Isler CM, Barrilleaux PS, Magann EF, Bass JD, Martin JN. A prospective, randomized trial comparing the
efficacy of dexamethasone and betamethasone for the treatment of antepartum HELLP (hemolysis,
elevated liver enzymes, and low platelet count) syndrome. American Journal of Obstetrics and
Gynecology 2001;184:1332-7.
Magann 1994a {published data only}
Magann EF, Perry KG, Meydrech EF, Harris RL, Suneet PC, Martin JN. Postpartum corticosteroids:
accelerated recovery from the syndrome of hemolysis, elevated liver enzymes, and low platelets
(HELLP). American Journal of Obstetrics Gynecology. 1994;171:1154-8.
Magann 1994b {published data only}
Magann EF, Bass D, Chauhan SP, Sullivan D, Martin RW, Martin JN. Antepartum corticosteroids: disease
stabilization in patients with the syndrome of hemolysis, elevated liver enzymes, and low platelets
(HELLP). American Journal of Obstetrics and Gynecology 1994;171:1148-53.
Magann EF, Bass D, Chauhan SP, Sullivan DL, Martin RW, Martin JN. Antepartum corticosteroids: disease
stabilization in patients with HELLP syndrome. American Journal of Obstetrics and Gynecology
1994;170:410-.
Vigil-De Gracia 1997 {published data only}
Vigil-De Gracia P, Garcia-Caceres E. Dexamethasone in the post-partum treatment of HELLP syndrome.
International Journal of Gynecology & Obstetrics 1997;59:217-21.
Yalcin 1998 {published data only}
Yalcin OT, Sener T, Hassa H, Ozalp S, Okur A. Effects of postpartum corticosteroids in patients with
HELLP syndrome. International Journal of Gynecology & Obstetrics 1998;61:141-8.
* indicates the major publication for the study
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Clarke 2000
Clarke M, Oxman AD. Cochrane Reviewers Handbook 4.1 [updated June 2000]. :-.
Crowley 1999
Crowley P. Prophylactic corticosteroids for preterm birth (Cochrane Review). Cochrane Database of
Systematic Reviews 1999:-.
Duley 1992
Duley L. Maternal mortality associated with hypertensive disorders of pregnancy in Africa, Asia, Latin
America and the Caribbean. British Journal of Obstetrics and Gynaecology 1992;99:547-53.
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Magann 1993
Magann EF, Martin RW, Issacs JD, Blake PG, Morrison JC, Martin JN. Corticosteroids for the
enhancement of fetal lung maturity: impact on the gravida with preeclampsia and the HELLP syndrome.
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Martin 1991
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patterns of disease progression and regression. American Journal of Obstetrics and Gynecology
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Martin 1997
Martin JN, Perry KG, Blake PG, May WA, Moore A, Robinette L. Better maternal outcomes are achieved
with dexamethasone therapy for postpartum HELLP (hemolysis, elevated liver enzymes and
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Pritchard 1954
Pritchard J, Weisman R, Ratnoff O, Vosburgh G. Intravascular haemolysis, thrombocytopenia and other
haematologic abnormalities associated with severe toxemia of pregnancy. New England Journal of
Medicine 1954;250:89-98.
Sibai 1986
Sibai BM, Taslimi MM, el-Nazer A, Aman E, Mabie BC, Ryan GM. Maternal-perinatal outcome associated
with the syndrome of hemolysis, elevated liver enzymes, and low platelets in severe pre-eclampsia-
eclampsia. American Journal of Obstetrics and Gynecology 1986;155:501-9.
Sibai 1993
Sibai BM, Ramadan MK, Usta I, Salama M, Mercer BM, Friedman SA. Maternal morbidity and mortality in
442 pregnancies with heamolysis, elevated liver enzymes, and low platelets (HELLP syndrome).
American Journal of Obstetrics and Gynecology 1993;169:1000-6.
Weinstein 1985
Weinstein L. Preeclampsia/eclampsia with heamolysis, elevated liver enzymes and thrombocytopenia.
Obstetrics and Gynecology 1985;66:657-60.
Yalcin 1998
Yalcin OT, Sener T, Hassa H, Ozalp S, Okur A. Effects of postpartum corticosteroids in patients with
HELLP syndrome. International Journal of Gynecology and Obstetrics 1998;61:141-8.
Yeast 1987
Yeast JD, Coronado S. Hepatic dysfunction, thrombocytopenia and late onset preeclampsia. A report of
three cases. Journal of Reproductive Medicine 1987;32:781-4.
G R A P H S
Graphs and Tables
To view a graph or table, click on the outcome title of the summary table below.
Dexamethasone plus standard treatment versus standard treatment alone
Outcome title
No. of
studies
No. of
participants
Statistical method Effect size
1 Maternal deaths 1 34
Risk Ratio (M-H, Fixed,
95% CI)
0.33 [0.01,
7.65]
2 Postpartum sepsis 1 30
Risk Ratio (M-H, Fixed,
95% CI)
2.0 [0.20,
19.78]
3 Mean platelet counts over 48 hours 1 34
Mean Difference (IV,
Fixed, 95% CI)
40.60 [-26.12,
107.32]
4 Mean hospital stay post randomisation Mean Difference (IV, -4.5 [-7.13,
28/08/13 cochrane.bvsalud.org/cochrane/show.php?db=reviews&mfn=1120&id=CD002076&lang=es&dblang=&lib=COC&print=yes
cochrane.bvsalud.org/cochrane/show.php?db=reviews&mfn=1120&id=CD002076&lang=es&dblang=&lib=COC&print=yes 10/12
(days) 1 30 Fixed, 95% CI) -1.87]
5 Neonatal deaths 1 25
Risk Ratio (M-H, Fixed,
95% CI)
0.36 [0.04,
3.02]
6 Neonates with intraventricular
hemorrhage
1 25
Risk Ratio (M-H, Fixed,
95% CI)
7.54 [0.43,
132.35]
7 Neonates with respiratory distress
syndrome
1 24
Risk Ratio (M-H, Fixed,
95% CI)
1.0 [0.25, 4.00]
8 Neonates with 5 minute Apgars less
than 7
1 24
Risk Ratio (M-H, Fixed,
95% CI)
1.0 [0.25, 4.00]
9 Weight at birth in grams 1 25
Mean Difference (IV,
Fixed, 95% CI)
247.0 [65.41,
428.59]
10 Neonates with retrolental fibroplasia 1 25
Risk Ratio (M-H, Fixed,
95% CI)
0.36 [0.02,
8.05]
11 Number of cesarean section
deliveries
1 34
Risk Ratio (M-H, Fixed,
95% CI)
0.93 [0.66,
1.31]
12 Time interval (hours) from
randomisation to delivery
1
Mean Difference (IV,
Fixed, 95% CI)
Totals not
selected
Dexamethasone versus betamethasone
Outcome title
No. of
studies
No. of
participants
Statistical method Effect size
1 Mean arterial pressure: adjusted time-
averaged change from baseline
1 40
Mean Difference (IV,
Fixed, 95% CI)
-7.50 [-8.37,
-6.63]
2 Urinary output (mL/h): adjusted time-averaged
change from baseline
1 40
Mean Difference (IV,
Fixed, 95% CI)
24.8 [19.58,
30.02]
3 Platelet count (10-9 cells/L): adjusted time-
averaged change from baseline
1 40
Mean Difference (IV,
Fixed, 95% CI)
8.1 [6.23,
9.97]
4 LDH activity (U/L mean): adjusted time-
averaged change from baseline
1 40
Mean Difference (IV,
Fixed, 95% CI)
-54.20
[-88.22,
-20.18]
5 AST activity (U/L): adjusted time-averaged
change from baseline
1 40
Mean Difference (IV,
Fixed, 95% CI)
-30.30
[-36.06,
-24.54]
6 Number of mothers with oliguria (less than 30
ml/hour for 2 hours)
1 40
Risk Ratio (M-H, Fixed,
95% CI)
0.06 [0.00,
0.93]
7 Maternal pulmonary edema 1 40
Risk Ratio (M-H, Fixed,
95% CI)
Not estimable
8 Number of participants needing acute
antihypertensive therapy
1 40
Risk Ratio (M-H, Fixed,
95% CI)
0.29 [0.12,
0.73]
9 Neonates with a 5 minute Apgar less than 7 1 39
Risk Ratio (M-H, Fixed,
95% CI)
0.95 [0.22,
4.14]
10 Neonates needing ventilatory support 1 39
Risk Ratio (M-H, Fixed,
95% CI)
0.54 [0.19,
1.56]
11 Neonates with respiratory distress syndrome 1 39
Risk Ratio (M-H, Fixed,
95% CI)
0.54 [0.19,
1.56]
12 Neonatal sepsis 1 39
Risk Ratio (M-H, Fixed,
95% CI)
4.76 [0.24,
93.19]
13 Neonatal hyperbilirubinemia 1 39
Risk Ratio (M-H, Fixed,
95% CI)
2.85 [0.32,
25.07]
14 Fetal or neonatal death 1 39
Risk Ratio (M-H, Fixed,
95% CI)
0.95 [0.15,
6.08]
15 Neonate time to discharge (days: mean) 1 39
Mean Difference (IV, -5.40 [-19.53,
28/08/13 cochrane.bvsalud.org/cochrane/show.php?db=reviews&mfn=1120&id=CD002076&lang=es&dblang=&lib=COC&print=yes
cochrane.bvsalud.org/cochrane/show.php?db=reviews&mfn=1120&id=CD002076&lang=es&dblang=&lib=COC&print=yes 11/12
Fixed, 95% CI) 8.73]
C O V E R S H E E T
Corticosteroids for HELLP syndrome in pregnancy
Reviewer(s) Matchaba Patrice T, Moodley Jagidesa
Contribution of Reviewer(s)
Issue protocol first published 2000 issue 2
Issue review first published 2004 issue 1
Date of last minor amendment Information not supplied by reviewer
Date of last substantive amendment Information not supplied by reviewer
Most recent changes
Date new studies sought but none found Information not supplied by reviewer
Date new studies found but not yet
included/excluded
Information not supplied by reviewer
Date new studies found and included/excluded Information not supplied by reviewer
Date reviewers' conclusions section amended Information not supplied by reviewer
Contact address Henderson
First Floor, Liverpool Women's NHS Foundation
Trust
Crown Street
One Health Plaza
Private Bag 7
Congella
Liverpool
East Hanover
Durban
UK
USA
South Africa
L8 7SS
NJ 07936-1080
4013
Telephone:
Facsimile:
E-mail: sonjah@liverpool.ac.uk
Cochrane Library number CD002076
Editorial group Cochrane Pregnancy and Childbirth Group
Editorial group code HM-PREG
S O U R C E S O F S U P P O R T
External sources of support
No sources of support supplied
Internal sources of support
Medical Research Council, South Africa.
28/08/13 cochrane.bvsalud.org/cochrane/show.php?db=reviews&mfn=1120&id=CD002076&lang=es&dblang=&lib=COC&print=yes
cochrane.bvsalud.org/cochrane/show.php?db=reviews&mfn=1120&id=CD002076&lang=es&dblang=&lib=COC&print=yes 12/12
K E Y W O R D S
Female; Humans; Pregnancy; Adrenal Cortex Hormones [*therapeutic use] ; Betamethasone [therapeutic use] ;
Dexamethasone [therapeutic use] ; HELLP Syndrome [*drug therapy] ; Randomized Controlled Trials as Topic
H I S T O R Y
History
Protocol first published: Issue 2, 2000
Review first published: Issue 1, 2004
Date Event Description
16 June 2008 Amended Converted to new review format.
Imprimir | Cerrar
Copyri ght: The Cochrane Li brary

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